Primary Contact Name: *
First
Last
Primary Contact Email: *
Primary Contact Phone: *
Primary Contact Mobile: *
Secondary Contact Email:
Organization Name: *
Organization Website:
Organization Type: *
Government
College/University
Public Schools
Corporation
Association
Non-Profit
Speaker-Series
Organization Sub Type: *
Education
Technology
Media/Broadcasting
Communications
Banking/Financial Services
Industrial
Transportation
Other
Other:
Additional Organization Details:
Event Name: *
Role Played in Event: *
Keynote Speaker
Award Reciepient
Panelist
Moderator
Donation
Guest
Date of Event: *
Alternate Date:
Keynote Topic: *
Event Start Time: *
1
2 3 4 5 6 7 8 9 10 11 12
:
00
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
AM
PM
Hour : Minute AM/PM
Speaker Start Time:
1 2 3 4 5 6 7 8 9 10 11 12
:
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
AM
PM
Speaker End Time:
1 2 3 4 5 6 7 8 9 10 11 12
:
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
AM
PM
Event Description: *
(include information on: Attire, format, luncheon, dinner, reception
theater seating, etc.) PLEASE DO NOT INSERT A PRESS RELEASE.
Panel Topic:
Panelists: Specific names and affiliations
(include all invited and their confimation status)
Venue Name: *
Address: *
Street Address *
Address #2
City: *
Zip/Postal Code *
State/Provence/Region: *
Country
Closest Airport to Venue: *
Audience:
(Please provide a description -- size, students, faculty, ceo, etc.)
What media outlets will be present at this event:
How is this event being promoted:
Organization will cover expenses: *
Yes
No
Expenses covered by organization:
Air Travel
Car Service
Hotel
Speaker may have products (books, etc.) available for the event. Would you be willing to provide personnel to help with these products?
Yes
No
Is there an Honorarium?
Yes
No
Honorarium Amount:
0 - $1,000
$1,000 - $2,500
$2500 - $5,000
$5,000 - $10,000
$10,000 - $50,000
Deadline for Response: *
Enter the code from the box above, then Submit